Wisteria Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility statment review the facility failed to ensure a safe smoking program and failed to assess a resident for safe smoking practices for one (1) of three (3) residents reviewed for accident hazards. Resident #17.FindingsRecord review of a typed statement on facility letterhead dated 3/11/26 and signed by the Director of Nursing (DON) revealed, (Name of Facility) does not have a policy requiring the completion of a smoking assessment for Residents who use tobacco products.On 03/09/26 at 11:41 AM, Resident #17 was observed eating lunch in his room with cigarettes visible in the front pocket of his shirt.On 03/11/26 at 8:18 AM, Resident #17 was observed traveling in a wheelchair down the hallway near the nurse's station with cigarettes in the front pocket of his shirt.During an interview on 03/11/26 at 12:53 PM, Certified Nursing Assistant (CNA) #1 stated the resident's family visits and the resident smokes outside with family members or a staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure staff followed infection prevention and hand hygiene practices during catheter care for one (1) of three (3) residents observed for infection control. Resident #32.Findings included:Record review of the facility policy Handwashing reviewed 1/25 revealed Policy: Employees must wash their hands using antimicrobial or non-antimicrobial soap and water; alcohol-based hand rub may be used if hands are not visibly soiled.After handling items potentially contaminated with blood, body fluids, or secretions .On 03/10/26 at 1:18 PM, Certified Nurse Aide (CNA) #1 was observed performing catheter care for Resident #32. During care, the resident's perineal area was observed to have an open area that was actively bleeding. CNA #1 wiped the resident's perineum four separate times using incontinent wipes while wearing the same gloves that had become visibly contaminated with blood. CNA #1 did not remove the contaminated gloves,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to expired foods, freezer burned foods, improperly stored foods, and unlabeled and undated foods for two (2) of (2) kitchen observations. Findings include: A review of the facility's policy, Handling of Perishable Foods, Revision Date: 09/2/2022 revealed, Policy: To ensure foods are protected from contamination or spoilage. Any growth of organisms is prevented by proper storage and temperatures .Policy .10. All items .will be properly labeled with the Item, Initials, Date and use by date .12. Any food items not properly stored will be disposed of immediately . On 02/18/2025 at 10:15 AM, during an observation of the kitchen and an interview with the Certified Dietary Manager (CDM), the walk-in refrigerator was observed to contain a one (1) gallon bottle of lime juice with a manufacturer's date of 07/18/2024 on the lid and a white cloudy film at the bottom of the bottle. There were (2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (5%) as evidenced by three (3) errors were observed out of 29 medication administration opportunities. This affected two (2) of four (4) residents observed during medication pass, resulting in a medication error rate of 10.34%. (Resident #43 and Resident #154) Findings Include: A record review of facility's policy Medication and Treatment Orders, undated, revealed, .Orders for medications and treatments will be consistent with principles of safe and effective order writing . Resident #43 A record review of the admission Record revealed the facility admitted Resident #43 on 01/20/2025 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Summary Report, with Active Orders As Of: 2/19/25, revealed Resident #43 ' s had a Physician ' s Order, dated 2/13/25 for Breo Ellipta Inhalation Powder Breath Activated, one (1) puff one puff inhaled orally once daily for COPD . On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record reviews, and staff interviews, the facility failed to correctly code a Minimum Data Set (MDS) discharge assessment for one (1) of fourteen (14) sampled residents reviewed for assessment accuracy. Resident #48 Findings Include: Record review of the facility's, Accurate Completion of Social Determinates of Health -Minimum Data Set (MDS) Policy dated October 2023 revealed It is the policy of this facility to ensure that . data are accurately captured within the MDS per the current Resident Assessment Instrument (RAI) Guidelines .The MDS Coordinator will ensure that these data elements are carried out timely and coded accurately . Record review of the Discharge Minimum Data Set (MDS) for Resident #48 revealed an admission date of 11/13/24. Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/24 in Section A revealed Resident #48 was discharged to an acute hospital. Record review of the facility's, Progress Notes revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure medications were safely and securely stored for one (1) of four (4) residents observed for medication administration. Resident #43 Findings Include: A record review of the facility's Medication Labeling and Storage revised 2/2023, revealed, .The facility stores all medication and biologicals in locked compartments .Medication Storage .2. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner . On 02/19/2025 at 9:45 AM, during an observation with Licensed Practical Nurse (LPN) #3, Albuterol Sulfate HFA Inhalation Aerosol Solution was observed on Resident #43's nightstand table in a clear plastic bag. On 02/19/2025 at 2:14 PM, during an interview, LPN #3 stated that no medications should be left at the bedside unless there is a physician's order permitting it. She explained that leaving medications at the bedside could result in the resident overdosing on the medication, which could cause damage to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency. Specifically, the facility was cited for failing to label, date, and discard expired items stored in the refrigerator, freezer, and dry storage room during an annual recertification survey on 10/19/23 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of six (6) deficiencies cited. F812 Findings Include: Review of the facility's policy Quality Assessment and Performance Improvement (QAPI) Program, undated, revealed .The facility shall .maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program .Committee Audit Process .2. The QAPI Committee shall help various departments .develop and implement plans of correction and monitoring approaches .3. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record and facility policy review, the facility failed to follow infection prevention guidelines in two (2) of (10) observed care procedures as evidenced by staff did not don (put on) appropriate personal protective equipment (PPE), including gowns, per Enhanced Barrier Precautions (EBP) during Percutaneous Endoscopic Gastrostomy (PEG) tube and Foley catheter care for Resident #43 and Resident #251. Findings Include: A record review of the facility's policy Enhanced Barrier Precautions dated April 2024 revealed .Policy Interpretation and Implementation: 1. EBP will be used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug resistant organism (MDROs) to staff . Resident #43 On February 19, 2025, at 1:42 PM, Licensed Practical Nurse (LPN) 1 was observed providing care to Resident #43's PEG tube site.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and the dry storage room were dated, labeled, and discarded by the expiration date for one (1) of three (3) dietary observations. This has the potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen) dated 2016, revealed, . Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration . An observation of the kitchen on 10/16/2023 at 9:15 AM, with the Dietary Manager (DM), revealed several expired food items. There were three (3) 46 ounce (oz). cartons of [NAME] Ready Care cranberry cocktail, with a received date of 11/22/22, and an expiration date of 2/23. There were six (6) 24 oz bottles of Hershey's chocolate syrup, with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record reviews, and facility policy review the facility failed to manage a resident's pain by not administering medication per physician orders for one (1) of three (3) residents reviewed for pain. Resident # 6 Findings include: A review of the facility policy, Pain Assessment Management, with a revision date of 9/2023, revealed, Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain . The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate . On 10/16/23 at 10:32 AM, in an interview with Resident #6, she revealed she has back and leg pain. She stated her pain is controlled by a pain patch on her back, but the nurse had told her that the facility is out of the patch. On 10/17/23 at 11:09 AM, during an interview with Resident #6, she commented that the facility was still out of her pain patch.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.